How Often Do You Need a Pap Smear? A Pelvic Exam? The Low Down on What’s Down Below!

The times are a-changing ladies! Routine annual pelvic exams have been thrown out the window because they are virtually useless, and as of last week, paps are now recommended only every 3-5 years if you have a normal pap/HPV history. And no paps before age 21 – ever!

The aim of pap smears is to identify high-grade precancerous cervical lesions and early-stage asymptomatic invasive cervical cancer. They can be very effective for this. But until recently, we were told we needed a pap annually, from the first time we opened our legs for a gynecology appointment in our teens or early 20s, until in our 60s. The awkward annual ritual of feet in stirrups followed by cervical scraping and probing fingers was believed to be a critical life-saving part of our all-important annual gynecology exams. In reality, for most of us, it wasn’t. And for many, more harm was done than good.

For decades, those of us challenging the ob-gyn status quo, particularly midwives, observed an alarming phenomenon: many young women who’d previously been subjected to LEEP procedures and Cone biopsies to burn, freeze, or cut out potentially pre-cancerous cells after “a bad pap” (Note: false positives were notoriously high with the older version of the pap smear) went on later to have difficulty with cervical dilatation during labor when they had babies. This was due to cervical scarring and stenosis as a result of the forementioned procedures. Many of these women ended up with cesareans because of “failure to progress” as a result. The failure was not in the women at all, but in an imperfect and often over-zealous gynecology system that tended to slash and burn first, ask questions later. I’d like to think the intentions were good, and some were, but big money has been made in the name of cancer prevention.

Well, ladies, it seems that in the past few years, someone’s been asking better questions and the low-down on pap and pelvics has been changing, practically in front of my very eyes. It’s about time!

First, a few years ago, the relationship between invasive cervical procedures and later problems with childbirth was recognized and acknowledged, along with the fact that most women under the age of 21 will spontaneously revert to a normal pap and will naturally clear the HPV virus (several strains of which are associated with cervical cancer) without any treatment. The risk of the pap leading to an invasive procedure leading to later childbirth problems outweighed the benefit of the pap – so women under 21 years of age, even if they’ve had a prior “bad pap” were told not have another pap until after their 21st birthday.

At around the same time The US Preventative Task Force (USPTF), the group that makes guidelines for medical practices, determined that paps every 2 years for women 21-29, and every 3 years for women 30-65 were adequate for early detection of cervical cancer, providing a history of normal paps and negative HPV viral testing. Then, somewhere in between, a solid evidence based review of the literature demonstrated that annual pelvic exams were obsolete in generally healthy people. They just didn’t provide enough useful information to justify being done.

And now the latest. The USPTF released a bulletin on March 12, 2012 stating that:

Screening women ages 21 to 65 years every 3 years with cytology [pap smear] provides a reasonable balance between benefits and harms. Screening with cytology more often than every 3 years confers little additional benefit, with large increases in harms. HPV testing combined with cytology (co-testing) every 5 years in women ages 30 to 65 years offers a comparable balance of benefits and harms, and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval.

So gals, you can stop worrying about the shave and a haircut, and your Sunday best panties every time you go in for your annual physical (and frankly, that might not be entirely necessary either) Most of you will be keeping your britches on. Of course, if you have concerning symptoms such as abnormal vaginal bleeding, signs of infection, a history of highly suspicious cells on your past paps, or persistent HPV, speak with your primary care provider about appropriate screening and follow-up. Cervical cancer screening is an effective tool for detecting cervical cancer. When used appropriately, the benefits outweigh the harms. Overused, the harms outweigh the benefits.

To summarize:
Under Age 21: no pap smear, no HPV testing
Age 21-29 Pap every 3 years
Age 30-65 Pap + HPV every 5 years

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31 Comment

Great article and so wonderful to read a positive health story in this day and age where negative, fear inducing stories abound. I was wondering - does one need to request the hpv test separately or does it 'come' with the new pap test? Also if you test negative for hpv are you always negative assuming you remain in a monogamous relationship?

I am one of those women who had an abnormal pap, a leep, then a cone biopsy which led to threatened preterm birth, cerclage, bed rest and failure to progress in labor. It was a very traumatic experience--an unnecessary one! I'm glad to know protocol is changing now. Thanks for sharing Aviva!

I had a mild to severe cervical dysplasia followed by a freezing - before my first child. I recently found out that even severe dysplasia has a 34% chance of clearing without treatment.
I did have a hard time dilating with my first birth, but it could have been caused by the pitocin/epidural combination, I will never know for sure.
I had normal paps in the past 7 years since my freezing and even my HPV came back negative the last time but still it is too scary not to do the yearly pap smears because I had a normal pap in 2004 and every time before that and then boom - all of the sudden in 2005 I was HPV positive and had mild to severe dysplasia. All this change in just one year, in spite that I was with the same man(my husband) since 1998.
Initially I oposed the freezing because I wanted to get pregnant and I knew that the freezing can damage the cervix but then one of my acquintances died of cervical cancer when her child was 1 year old and I was so afraid that it will happen to me too, that I took the chance.
I think that quitting smoking, eating organic and dumping out chemicals from my house definitely contributed to the normal paps that I have been having since. Still, every year, when I do the test and I have to wait a week for the results - I am a nervous wreck.

I have never had a bad pap or hpv but found a lump on my cervix and it turned out to be stage 1b2 cervical cancer with metastasis to the lymph. That was in less than 2 years. It makes me sick to see these new guidelines.

Tonia

I agree, with The new Obama care comming. into effect it Make me wonder if they Are doing This To cut back for funds and ofcorse more women will have hpv and overtly The. ideale idea Is that they being The government because they Are now in control dont care ... This Sounds rediculas and absurd. I really would like To read about These so called statts on more women being harmed Then Good. i grew up believing that Its better To be safe than sorry.

I have never had a bad pap or hpv but found a lump on my cervix and it turned out to be stage 1b2 cervical cancer with metastasis to the lymph. That was in less than 2 years. It makes me sick to see these new guidelines.

Tania

This only proves that Pap smears are extremely unreliable and useless in cancer prevention, regardless of how often they are done. They tend to miss the most dangerous and fast growing cancers even if done annually. But they are very "good" at detecting harmless, self-healing abnormalities, and lead to unnecessary biopsies and treatments. More harm than good indeed.

aviva

admin

Your doc or midwife or nurse practitioner will order the hpv if you are over 30; under 30 it will come as a reflex test. That means if you have any abnormal cells on your pap, HPV will be done automatically. ~Aviva

admin

Thank you for sharing this! This is one of the reasons that I have concerns about women abandoning self-breast exams. I've worked with dozens of women who "found a lump" that turned out to be something that nobody else would have found... I am a strong proponent of women continuing to have paps. I think that we just have to keep in mind how many women are harmed by the overuse of procedures and interventions and find a healthy balance. I hope you are long recovered and thrivingly well! ~Aviva

admin

Yes this is very stressful and of course, do the paps! Peace of mind is priceless! And for the ladies reading this, smoking is a huge risk for cervical cancer. HPV migrates and collects in cells affected by cigarette smoking, and cervical cells are especially vulnerable to the effects of cigarette smoking.

YES!!! I just went to Dr. last week. He wanted to do a PAP. I said NO. I'm 67 years old had a TAH at 42(cuz I had a few fibroids & wanted it), have never had a suspicious exam & no history of any female organ cancers back thru great-grandmothers on both maternal & paternal sides, & I am not sexually active & quit smoking 6 or so years ago. The test is always painful & have had excessive bleeding. Dr. had fit out of my presence but within earshot. I hope he got some new guidelines on this by now.

Actually there is no difference between 5 yearly and annual pap testing as far as benefit is concerned, but the more often you test, the more likely you'll get a false positive and be referred for biopsy/over-treatment. Finland has the lowest rates of cc in the world and send far fewer women for colposcopy/biopsy, they offer 7 pap tests, 5 yearly from 30 to 60. The Dutch have the same program, but are likely to move to a new program, already recommended by their Health Council...women will be offered 5 hrHPV primary triage tests at 30,35,40,50 and 60 and only those positive will be offered a 5 yearly pap test. Those negative will be offered the HPV program or if monogamous or no longer sexually active might choose to forget all testing and revisit the subject if their risk profile changes. Only 5% of women are HPV positive by age 30; most are not destined to get cc, but have a small chance of benefiting from pap testing. HPV negative women can't benefit from pap testing. Sadly, not one country in the world has shown a benefit pap testing those under 30, it doesn't change the tiny death rate, but young women produce the most false positives, 1 in 3 tests for those under 25. HPV testing is not recommended either before age 30 as around 40% of young women would test positive but almost all will clear the infection within a year or two.
The new Dutch program is more likely to prevent/catch these rare cancers and will better protect the vast majority of women who can never benefit from pap testing. (lifetime risk of cc is 0.65%...take out false negatives and consider natural decline and fewer than 0.45% can benefit from pap testing)
The Dutch are also using the Delphi Screener, the reliable self-test HPV option..it was launched in Singapore recently and elsewhere. Australia seriously over-screens women and we have huge referral/over-treatment rates...cone biopsies and laser treatments can damage the cervix and lead to cervical stenosis, infertility, c-sections, cervical incompetence, premature babies, the need for cervical cerclage, endometriosis etc
Our program is excessive and harmful and more than a decade behind the evidence...women are being harmed by this program, yet our doctors are silent...enjoying enormous profits from over-treatment and collecting incentive payments for reaching screening targets.
As a low risk woman, I got to the facts many years ago, my risk of cc is near zero, the risks were too high for me, I have always declined to test and recently also declined breast screening. I believe over-diagnosis is a serious and hidden risk with breast screening and the benefits have been greatly overstated. Women's cancer screening is IMO loaded with political and vested interests...I'd urge every woman to do some reading, understand what you're agreeing to...And look closely at those who aggressively push screening, is there a conflict of interest?
This doctor also declines pap testing...see, "Why I say no to a smear" by Dr Margaret McCartney which appeared in the Independent (UK) recently. This doctor has also written an excellent book on the subject, "Patient Paradox".
Refs: A very important and unbiased brochure for those thinking of breast screening..."The risks and benefits of mammograms" at the website of the Nordic Cochrane Institute, an independent medical research group. Also, Dr Joel Sherman's Medical Privacy Forum - see section on women's privacy concerns parts 1 to 7 and see medical journal references in the side bar. The Dutch program is outlined at the website of the Health Council of the Netherlands and the Delphi Bioscience website contains info on the Delphi Screener. Good luck everyone...

Lark

I winced at "the shave and a haircut" because it summoned for me visions of tampering with pubic hair and I would never ever ever!!!! Don't wax or trim of slice or shave or snip, leave it alone!
Had abnormal Pap 20 years ago, cryotherapy, no recurrence, all normal until this summer (ASCUS), HPV+, had LEEP because colposcopy was impossible. LEEP showed nothing at all, no ASCUS, no dysplasia, nothing. I had tried to persuade both doctors to just wait and do a second Pap. I think LEEP was unnecessary but it was a breeze and I wasn't using those cells anyway (had my one kid). Now when I go for followup I will say I want to wait at least a year for another Pap.....
I don't see Paps as invasive; it's the cost that is annoying.

gauri

I read this again after working in a busy gynae clinic in an area where HIV is 33% and the cervical cancer risk is increased in HIV. What are your thoughts or suggestions in this population, based on the research? Thanks. Gauri

aviva

Hi Gauri, Guidelines for women with high risk should absolutely be followed in a high risk community. This website is a reliable resource for pap and colpo guidelines. Best, Aviva
http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx

Medical Patient Modesty

Dr. Aviva,
I appreciate your information about false positive pap smears and the consequences of leep procedures and cone biopsies.
However, the guidelines still do not take into consideration that some women may actually not ever need pap smears and that some women may need pap smears more often. For example, virgin women (regardless of age) who have never engaged in any kind of sexual activity really do not need a pap smear.
I encourage you to check out this article: Truth About Pap Smears (http://patientmodesty.org/papsmears.aspx).
What are your thoughts on the above article?
Misty

aviva

Hi Misty,
I have not had a chance to read the article, but you are correct, as long as a woman has never had sexual activity she might not need a pap -- though a very small percentage of women can still have contracted HPV (it is unclear how this happens) and develop cervical cancer -- but this would be extremely unlikely!

Medical Patient Modesty

The article mentioned some factors that could slightly raise a true virgin's woman's chance of getting HPV infection or cervical cancer. Number 2 has nothing to do with HPV. I heard that cervical cancer caused by DES is very rare though.
1.) Based on some studies, smoking could possibly cause cervical cancer without HPV infection.
2.) Mother took DES (also known as diethylstilbestrol) during pregnancy with you between 1938 - 1971 to prevent miscarriage and premature delivery. It is estimated that only 1 in 1,000 women who were exposed to DES in the womb will develop cervical cancer.
3.) Mother had HPV infection when she gave birth to you (only applies to vaginal birth). The risk of HPV transmission to the baby during childbirth is very low. Even if babies do get the HPV virus, their bodies usually clear the virus on their own. (Source: HPV and Pregnancy).
4.) You had a Pap smear with an unsterile speculum.
I read some sources where some women can get HPV from sharing towels or underwear with HPV infected people.

Medical Patient Modesty

Dr. Aviva,
Have you ever read this article about how informed consent is missing from pap smears by Dr. Sherman at http://www.kevinmd.com/blog/2009/11/informed-consent-missing-pap-smears-cervical-cancer-screening.html?
Misty

aviva

Dominique

I love this article. It really enlightened me. I'm still a bit confused and a tad lost. If you could help, I would like to know:
Girls under 21 cannot get a pap smear or HPV testing. But, girls under 21 can receive a ParaGrad? Which is kind of the same process as a pap smear I believe (Correct me if I'm wrong). I would like to know if this correct, if so, why is that? Please and Thank you ^_^

aviva

It's because almost everyone under 21 will clear HPV naturally and so paps would pick it up in people who shouldn't be treated. Years ago girls were getting LOOPs and cone biopsies, only for gynecologists to discover these were unnecessary and also led to scarring that later prevented many of these women's cervices from dilating for birth! The paragard is a totally different issues -- it's birth control that is inserted into the uterus via the cervix and is safe for young women.

Benita

Hello, I am almost 37 years old, tested positive for high risk HPV for past five years. Recent pap shows it is still there. For the past five years I had as follows; abnormal pap, normal pap, abnormal pap, colpolscopy, recommended LEEP, declined and treated with herbs and colloidal silver, repeat colposcopy came out much improved after treatment. Then I had two normal paps six months apart. My recent pap last week came back abnormal again HGSIL and so I have another colposcopy scheduled for end of august. I am thinking of treating again before the colposcopy so that I don't get recommended the LEEP again. I don't want to get that because I want to have another baby. I had planned to get pregnant in the next few months. Would you recommend waiting until I get a normal pap?

Parma Deas

aviva

Hi Parma,
If you are concerned, it is reasonable to request that your gyne or family doctor do a pelvic exam. However, this would not assess for ovarian cancer, for which there is no routine screening, though a CA 125 can be tested for. Thank you for writing!

anonymous

I was tested positive for HPV (low risk) 3 years ago and haven't been tested since, though did have an exam 2 years ago (after a D and C). Wondering if I need to schedule a gyn exam and/or pap and/or HPV test or can wait another couple of years? I don't have any red flags (just occasional vaginal itchiness with too much honey or fruit). Aviva, would really appreciate your words of wisdom! I am a big fan!